Among patients with complex lesions who underwent optical coherence tomography (OCT)-guided PCI, long lesions and small vessels were identified as major determinants of OCT suboptimization, and achievement of successful stent optimization was significantly associated with improved clinical outcomes, according to a post hoc analysis of the OCCUPI trial, published Nov. 25 in EHJ.

Seung-Jun Lee, MD, et al., investigated the incidence, predictors and clinical implications of stent optimization among 773 patients who underwent OCT-guided PCI from the OCCUPI trial (median age, 64 years; 19% women), and classified them according OCCUPI-OCT criteria; 549 patients (71%) achieved OCT optimization criteria and 549 did not (OCT suboptimization). Results showed that on multivariable analysis, long lesions (≥28 mm) and small vessels (<2.5 mm) were significant independent predictors of OCT suboptimization.

Findings also revealed that at one year, the primary endpoint (the cumulative incidence of cardiac death, myocardial infarction, stent thrombosis,or ischemia-driven target vessel revascularization) was significantly reduced in patients with OCT optimization (2.9%) compared with those with OCT suboptimization (9.4%, p<0.001) or angiography guidance (7.5%, p<0.001).

Notably, each component of OCCUPI-OCT criteria was independently and significantly correlated with favorable outcomes (all p<0.001), including assessment of stent expansion (minimal stent area, ≥80% of the mean reference lumen or ≥100% distal reference lumen areas; >4.5 mm2), apposition (malapposed distance, <400 μm), and absence of major edge dissection.

Importantly, the authors summarize what is needed for improved, successful outcomes of OCT-guided PCI of complex lesions: "a comprehensive evaluation of stent morphology, considering the three key components of stent optimization as defined by the OCCUPI-OCT criteria, along with maximal efforts to achieve stent optimizations."

In an accompanying editorial comment, Fernando Alfonso, MD. PhD, and Francesco Prati, MD, write that although "overwhelming evidence" supports the value of intracoronary imaging guidance (e.g., OCT) to improve clinical outcomes after PCI, "systematically implementing" its use "to optimize stent implantation in routine clinical practice will represent a major sea change." They list hurdles, including "the cost of the imaging catheters, the time required for imaging, and the ability of the operator to obtain, interpret, and react to the images." They also note that artificial intelligence "will be instrumental in facilitating this paradigm shift."